EP387 - The Negative Impact Of STARR In Patients Who Underwent Surgery For Internal Rectal Prolapse, Rectocele And Obstructed Defecation Syndrome Recurrence

Purpose/Background: The Stapled Trans-Anal Rectal Resection (STARR) procedure was developed as a minimally invasive transanal technique to treat not only hemorrhoidal disease but also anatomical rectal abnormalities like internal rectal prolapse (IRP) and rectocele, which can lead to obstructed defecation syndrome (ODS). Although STARR was initially met with significant enthusiasm, growing evidence has raised concerns about its long-term efficacy and the risk of serious complications. This study aimed to analyze the characteristics and outcomes of patients who underwent surgery for recurrence of IRP, rectocele, and ODS following STARR procedure, with a focus on very long-term follow-up data.

Methods/Interventions: A prospective single-center observational study was conducted on patients who underwent abdominal and perineal surgery for IRP with or without rectocele and entero/sigmoidocele at a tertiary referral center between November 1998 and January 2025. Patients previously treated with STARR procedure were specifically analyzed. Baseline characteristics, clinical, and radiological findings were collected. Surgical approaches were categorized as abdominal (Ventral Mesh Rectopexy - VMR, Orr-Loygue, Frykman-Goldberg) or perineal (internal Delorme's procedure, transvaginal rectocele repair) depending on the surgeon's experience and preference. All operations were performed by a single experienced colorectal surgeon (C.R.). Surgical complexity related to the STARR suture, postoperative complications, and recurrence were recorded at the last patient's follow-up visit, along with Altomare ODS and Cleveland Clinic Fecal Incontinence scores before and after surgery.

Results/Outcomes: Out of 376 patients, 50 females (13.3%) with a history of STARR surgery underwent surgery for recurrence of IRP, rectocele, and ODS. Regarding defecographic findings, IRP and rectocele were both detected in 42 of the 50 STARR patients (84.0%), with a mean rectocele size of 40.4±15.0 mm. Entero- or sigmoidocele was found in 33 cases (66.0%). Forty-five patients had abdominal procedures (41 VMR, 2 Orr-Loygue, 2 Frykman-Goldberg), and five underwent perineal techniques (4 transvaginal rectocele repair, 1 internal Delorme's procedure). During rectovaginal dissection, in three cases, the STARR suture could not be safely overcome due to technical difficulty (2 during VMR, 1 during transvaginal rectocele repair), as shown in Figure 1. At a mean follow-up of 76.3±71.9 months, postoperative complication rates were similar between the STARR and non-STARR groups (19.0% vs. 18.4%). One patient experienced persistent chronic pelvic pain due to the stapled suture despite anatomical correction. Recurrence occurred in 5.9% of cases, with comparable rates in both groups (4.8% vs. 6.1%). Overall, Altomare ODS and Cleveland Clinic Fecal Incontinence scores improved significantly. However, patients with prior STARR showed higher Altomare ODS scores both before and after surgery (Figure 2).

Conclusion/Discussion: Surgery for recurrence of IRP, rectocele, and ODS after STARR is feasible but challenging. Long-term results showed that previous STARR is linked to more severe baseline ODS symptoms and less functional improvement. These results suggest that STARR may not only be unsuccessful but could also complicate further surgeries due to altered anatomy and scarring. Careful preoperative assessment and counseling are crucial, while abdominal procedures like VMR may provide safer and more comprehensive treatment for patients with IRP, rectocele, and ODS.

Figure 1
Technical difficulty to overcome STARR suture during rectovaginal dissection in robotic ventral rectopexy. The white arrow indicates a clip of the STARR suture. V= posterior vaginal wall; R= anterior rectal wall.
Figure 2
Pre- and postoperative Altomare Obstructed Defecation Syndrome and Cleveland Clinic Fecal Incontinence scores in patients with or without previous STARR procedure who underwent surgery for internal rectal prolapse, rectocele and Obstructed Defecation Syndrome. STARR= Stapled Trans-Anal Rectal Resectio; ODS= Obstructed Defecation Syndrome; CCFI= Cleveland Clinic Fecal Incontinence score; Preop= preoperative; Postop= postoperative; n.s.= no statistically significant